Barriers to Obesity Management in Kidney Failure Before Transplantation

The first systematic review to synthesize both patients’ and clinicians’ perspectives on obesity management in kidney failure prior to transplantation has revealed significant challenges, highlighting the need for more equitable access to transplant care.¹

The review, which analyzed 7 studies with 738 participants, identified multiple barriers affecting patients’ ability to lose weight and clinicians’ capacity to provide support, including dialysis-related fatigue and hunger that limit lifestyle modification, weight stigma and poor communication in clinical settings, limited access to structured weight-management resources, and strict BMI-based eligibility criteria that may restrict equitable access to transplantation.¹

“These biases influence how clinicians communicate and whether they offer meaningful support, as we can see from previous data, and they can make patients feel fearful, ashamed, and less willing to engage,” said Adrian Brown, PhD, NIHR Advanced Fellow and Associate Professor in Nutrition and Dietetics at University College London and programme co-lead of the MSc Dietetics (Pre-registration) course. “What we have seen is that patients who feel stigmatized are less likely to actually come back to that clinician for support.”

Obesity is increasingly recognized as a risk factor for developing and progressing chronic kidney disease (CKD), linking weight management directly to transplant eligibility. Many transplant centers require patients to reach a body mass index (BMI) of 35–40 kg/m² to be listed for kidney transplantation, excluding a substantial proportion of otherwise eligible candidates. Understanding the lived experiences of both patients and clinicians is therefore essential to developing practical, fair, and effective approaches to weight management.²

Across the 7 included studies, patients’ mean age ranged from 54 to 58 years, with mean BMI 27.3 and 39.5 kg/m². In studies reporting ethnicity, patients were predominantly Black or White, with up to 78.8% identifying as Black in some U.S. cohorts.¹

Patients described significant barriers to weight management, including fatigue and hunger associated with dialysis, which made it difficult to adhere to dietary and activity recommendations. They reported experiencing weight stigma, feeling blamed or infantilized, which in turn undermined motivation to lose weight. Limited access to structured support and resources, including healthy foods, compounded these challenges. Many patients also expressed frustration with rigid BMI thresholds, viewing them as arbitrary measures that unfairly restricted access to transplantation.¹

“Clinicians, meanwhile, expressed their own challenges,” the investigators explained. “Many felt that they lacked training and knowledge about obesity, were uncertain how to safely support weight loss, and described competing clinical priorities, limited time, and difficulty initiating weight discussions—particularly in the busy and cognitively taxing dialysis environment.”

The review emphasizes the urgent need for targeted strategies to address these barriers. Recommendations include specialized training for clinicians on obesity management and weight bias, structured multidisciplinary support programs for patients, and more nuanced transplant eligibility criteria that move beyond BMI alone.

By integrating patient and clinician perspectives, the findings underscore the importance of compassionate, individualized approaches that account for the physical, emotional, and systemic challenges faced by people with kidney failure.

Editor’s Note: Brown reports relevant disclosures with Novo Nordisk and Reset Health.

References

1. Oganesova Z, MacLaughlin HL, McCafferty K, et al. Patient and clinician perspectives on the management of obesity in kidney failure prior to kidney transplantation: a mixed-methods systematic review. eClinicalMedicine. 2026;91:103649. doi:https://doi.org/10.1016/j.eclinm.2025.103649

2. ‌Johansen KL. Obesity and Body Composition for Transplant Wait-List Candidacy—Challenging or Maintaining the BMI Limits? Journal of Renal Nutrition. 2013;23(3):207-209. doi:https://doi.org/10.1053/j.jrn.2013.02.005